Intestinal Stomas—Current Practice and Challenges: An Institutional Review

INTRODUCTION

A stoma is an artificial anastomosis of the gastrointestinal tract to the abdominal skin wall to reroute the stream of feces.¹ Fecal diversion, bowel decompression, and anastomosis protection are common indications for stomas.²Other indications include obstruction due to benign and malignant tumors, perforation and peritonitis, inflammatory bowel disease, complex fistulas, mesenteric ischemia, and anorectal malformations.³ Temporary stomas can be done in cases of high-risk anastomosis and when the anastomosis is unsafe.⁴

Stomas can be classified according to stoma type (Loop, End, or Double-Barreled), the anatomical site (Colon or Ileum), or the purpose of the stoma (Temporary or permanent).³ Stomas have a high complication rate relative to other surgical procedures, with a rate averaging 40% and ranging from 14 to 79%.^5,6 Stoma complications are classified as immediate (24 hours), early complications (which occur within 30 days of surgery), and late complications (more than 30 days after surgery), immediately – prolonged ileus and oozing. A 2015 systematic review showed that stomas and their complications affected the quality of life negatively.

Peristomal skin irritation has been observed to be the most common early complication.⁷ In comparison, parastomal hernias were the most common late complication.⁸ Other common complications were prolapse, stomal retraction, vascular compromise, peristomal infection, and early postoperative bowel obstruction.^9–12

Risk factors associated with stoma complications include age, gender, high BMI, use of steroids, immunosuppressants, diabetes mellitus, emergency surgery, old age, ethnic group, gender, malnutrition, bowel distension, and high American society of anesthesiology score.^4,6,9–13 Furthermore, concomitant chemotherapy and radiotherapy increases the risk of peristomal skin complications.¹² Risk factors pertinent to surgical practice also affect the stoma complication rate. Ileostomies are associated with a better quality of life than colostomies. However, they are associated with a higher ileus and bowel obstruction rate than colostomies.¹² Additionally, preoperative and postoperative education by an ostomy nurse decreases the risk of complications.¹² Ostomy siting should also be done before the procedure by an ostomy nurse or a colorectal surgeon. It decreases the risk of leakage and dermatitis and improves the patient’s ability to adapt to the stoma.¹⁰ Bowel quality could also act as a risk factor, patients with Crohn’s disease have a significantly higher risk of stomal necrosis, retraction, and pyoderma gangrenosum.^14–16 Moreover, intraoperative complications such as bleeding can increase the risk of stoma complications.⁴

AIMS AND OBJECTIVES

Stoma complication rates are widely variable in literature.¹⁷ In our study, we determined the ostomy complication rate in Bahrain and describe how risk factors relate to different ostomy complications. This analysis will compare the findings with other highly referenced studies.⁵ Stoma complications are highly variable between studies, a study by Carlson et al.¹⁶ assessed the incidence of stoma-related complications within 1 year and reported a 36% complication rates, 11% of which were peristomal skin complications. Additionally, 88% of the patients had their ostomy appropriately sited preoperatively. However, 37% of emergent cases did not have the stoma location appropriately sited.¹⁶ Our study will also act as a benchmark for future outcomes pertinent to stoma care. Moreover, the study will measure the rates of proven methods to prevent stoma-related complications such as preoperative patient education, follow-up treatment, and ostomy siting.¹⁸

STANDARDS AND METHODS

This research was conducted after ethical approval 21-432 at KHUH in the Kingdom of Bahrain.

Our study was inclusive of patients who had undergone ileostomies and colostomies. The inclusion criteria included adult patients who were 15 years and older, both emergency and elective cases, and with an ASA score of 1–4. Patients who had their stoma performed outside of KHUH as well as patients who were not following up in the hyperbaric department of our hospital were excluded from our study.

This research study was performed using a retrospective study design. Our sample size was known to have 98 patients with stomas. These patients were following up with the hyperbaric team between January 2018 and February 2021.

Electronic medical records of all patients in the inclusion criteria was assessed. Preoperative, intraoperative, postoperative, and follow-up data were collected. For the preoperative period, routine patient level stratification of the risk of developing stoma complications was recorded.

Patient demographics, such as age, gender, weight, medications used, comorbidities, such as hypertension, diabetes, dyslipidemia, ischemic heart disease, and renal failure were collected.

Clinical details like diagnosis and indication of stoma creation (benign or malignant), type of surgery, and presence of preoperative tumor-related complications like anemia or obstruction was also recorded. Whether the patient received preoperative patient family education, stoma site marking, and neoadjuvant concomitant was noted.

For the preoperative period, routine patient level stratification of the risk of developing stoma complications was recorded. This included the patient’s age, gender, weight, comorbidities (hypertension, diabetes, dyslipidemia, ischemic heart disease, renal failure, etc.), and medications used by the patient. The diagnosis and indication of stoma creation, and whether the indication was benign or malignant was indicated in our data. The surgery was performed at KHUH on either an elective or an emergency basis.

Preoperatively, we looked at the presence of the tumor and its related complications, such as anemia or obstruction, stoma site marking, and if the patient received nonadjacent concomitant chemoradiotherapy, as well as patient family education.

For the intraoperative period, the following factors were assessed: American Society of Anesthesiologist (ASA) risk, Stoma type performed (ileostomy vs colostomy), and whether it was temporary or permanent. Additionally, the type of surgery performed, such as right colonic resection, left colonic resection, low/ultralow anterior resection, abdominoperineal resection, total proctocolectomy.

Postoperative period included the duration of stay in the hospital, and whether the patient received chemotherapy, radiotherapy, or any additional surgery. The factors studied after discharge were early versus late complications, and the duration of the stoma when the complication appeared. Furthermore, we kept track of the adherence to follow-ups with the hyperbaric team.

RESULTS

We analyzed 98 stoma cases in this study with various criteria as independent points of comparison by statistical methods (SPSS v 25.0). Table 1 presents the epidemiological data of all patients included in the study. The age of our cohort ranged between 48.25 and 67, with the average age being 60. The cohort was made up of 50 males and 48 females, with the majority being of Bahraini ethnicity (86.7%). The various clinical criteria are displayed in Table 2. The complications were sectioned into early and late complications as evidenced in Table 3.

The breakdown of indications for stoma formation is shown in Figure 1. The most common indication was colon cancer, accounting for 55% of all cases. Other specific indications like diversion for wound infection, volvulus, perforation, bowel obstruction, among others are laid out in the figure.

The cohort of stoma cases considered in our study had a total rate of complications of 65.3%. The most common of these were cutaneous complications, stoma retraction, prolapse, and bleeding, accounting for rates of 63.3, 22.4, 16.3, and 16.3%, respectively. The breakdown of all our documented complications is displayed in Figure 2.

DISCUSSION

A systematic review of randomized controlled trials revealed that stoma complication ranges from 2.9 to 81.1%.¹⁹ The 65.3%, with 54 cases out of 98 cases developing complications.

We have divided our complications into two categories: Early vs Late. Early complications include infection, bleeding, stoma necrosis, retraction, electrolyte imbalance, bowel obstruction, cutaneous complications, and stenosis. Late complications included prolapse, parastomal hernia, bowel obstruction, and retraction. Additionally, each complication was divided based on the elective vs emergency procedure. However, our study found no difference between the rate of complications based on emergency vs elective procedures for all complications.

Overall, in our study, the lowest complication rate was seen in stoma necrosis (2.0%), with a higher rate seen with ileostomy (2.6%) as opposed to colostomy (1.7%). On the other hand, the highest complication rate was seen in cutaneous complications (63.3%), with a higher rate seen with ileostomies (79.5%) as opposed to colostomy (53.4%).

Other common complications included retractions (22.4%), bleeding (16.3%), prolapse (16.3%), and electrolyte imbalance (12.4%).

CONCLUSION

Within our institutional study, 63.3% of stoma complications were composed of skin problems. This formed the majority of complications. Designing a stoma care unit would offer continuous support and care to the patients and aid them and their families in getting back to the best quality of life. This goal will be achieved through preoperative and postoperative education with regards to surgery and stoma formation. This consists of preoperative stoma marking and siting, as well as improved recovery through guidance from well-informed stoma care specialists regarding hands-on stoma care. Lastly, patients and caregivers will be assisted through specialized stoma clinics.

ORCID

Tabarak Qassim https://orcid.org/0000-0002-9839-6634

Mirza Faraz Saeed https://orcid.org/0000-0002-0343-2146

Isam Mazin Juma https://orcid.org/0000-0003-4470-677X

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